Encyclopedia of

Mortality, Childbirth

Until the late twentieth century, and then only in developed countries,
the mortality risks associated with childbearing were substantial.
Although there are risks to infants, the following entry focuses on the
mortality risks faced by mothers. Maternal mortality is measured by the
maternal mortality ratio, which is the number of deaths related to
pregnancy per 100,000 live births.

Getting an accurate measure of the maternal mortality ratio in many parts
of the world is difficult primarily because one needs reliability in both
the number of pregnant women and in the number of live births. A pregnant
woman may die, perhaps due to an illegal abortion, but her death is not
counted as pregnancy related either because her pregnant status is not
ascertained or that information is withheld due to religious/moral
convictions. In addition, maternal deaths extend to forty-two days past
delivery or past pregnancy termination; if a woman is not receiving any
medical care in the immediate postpartum period, her death may not be
attributed to childbearing. The number of live births is not available in
the countries that do not have a birth registration system. Even among
countries that do, there may be systematic differences between countries
in the designation of a birth as "live." Thus statistics on
maternal mortality for all but the most developed countries are best-guess
estimates only.

Global Variation in Maternal Mortality

At the turn of the twenty-first century, there were substantial
differences in maternal mortality. According to Women's
International Network News figures, the number of maternal deaths
worldwide per 100,000 live births is 430, with a sharp division between
developing countries, where the maternal mortality ratio is estimated to
be 480, and developed countries, where the ratio is 27. These ratios can
be translated into women's lifetime risk of dying from
pregnancy/pregnancy-related reasons: 1 chance in 48 in the third world
contrasted with 1 in 1,800 in developed countries. The highest maternal
mortality levels are found in eastern and western Africa;
Mozambique's maternal mortality ratio is among the highest in the
world at 1,500. The lowest levels occur in northern Europe.

Causes of Maternal Mortality around the World

Maternal mortality is the result of any number of complications that beset
pregnant women worldwide. The most common direct causes of maternal death
are severe bleeding (25%), infection (15%), unsafe abortion (13%),
eclampsia (pregnancyinduced hypertension, often accompanied by seizures,
12%), and obstructed labor (8%). Fundamental to the reduction of maternal
mortality is the identification of the wider social, economic, health, and
political factors that are associated with it, an area that is the subject
of considerable debate among policymakers. Some argue that maternal
mortality is an unusual public health problem in that it is primarily
affected by institutionally based medical interventions. This viewpoint is
unusual in that most causes of death have responded more to public health
initiatives (e.g., clean drinking water, sanitation) than to medical
interventions. According to this view, the way to reduce maternal
mortality is through the provision of emergency obstetrical care. In
contrast, others argue that the key factor in maternal mortality is the
disadvantaged status of women, a position that reframes maternal death as
a social justice issue. Maternal mortality is viewed as the accumulation
of a number of risks that girls and women face (e.g., malnutrition, female
genital mutilation, premature marriage and pregnancy, lack of family
planning mechanisms for child spacing) that reflect the relative lack of
status and worth accorded to them in certain countries.

Both medical and social factors play important roles in maternal
mortality. There is clear evidence that medical interventions are
important in reducing maternal mortality, as long as those interventions
are performed by trained personnel. Especially important is competent
emergency obstetrical care. Research done in rural Gambia shows that
prenatal care is far less effective than emergency care in reducing the
rate of death related to childbirth. This fact may be because many of the
life-threatening complications that accompany pregnancy and delivery
cannot be predicted for individual women. Also important is the provision
of family planning services, which operate to lower the number of births
and thus reduce the risk of maternal death. Evidence on the importance of
social factors in maternal mortality is less well documented. Overall
maternal mortality is much lower in societies in which women have higher
educational levels and higher social status. However, there is no direct
one-to-one relationship between improvements in women's social
conditions and reductions in maternal mortality. Nevertheless, access to
legal abortion is important in reducing deaths because legal abortions are
more likely to be performed in a clean environment by trained medical
personnel. It is estimated that about one-half of abortions lead to
maternal death in Indonesia where abortion is illegal; this translates to
the deaths of nearly 1 million women per year. In certain third world
countries, the provision of safe and legal abortion is bound up with
cultural views about gender roles, and is intimately related to
women's position in society.

Maternal Mortality in the United States

Figure 1 shows the trend in the maternal mortality ratio in the United
States over the course of the twentieth century. Maternal mortality ratios
were over 600 (somewhat higher than in the contemporary developed world)
until the early 1930s, when decline commenced. (The high rates around 1920
are likely due to the global influenza epidemic.) Compared to general
American mortality decline, this is a late starting date; reductions did
not occur despite an increasing proportion of deliveries in hospitals, the
introduction of prenatal care, and the increased used of antiseptics in
labor and delivery. Tworeasons have been given for the lack of reduction
in maternal mortality during the first third of the
twentieth century: Women either received no care or care in which the
attendant did not recognize the severity of complications; and women
received improperly performed medical interventions. It is likely that the
second reason was more of a factor because unnecessary or improperly
performed interventions and a lack of careful antiseptic procedures were
common during that time period.

The huge decline from the mid-1930s to the mid-1950s (from 582 to 40) has
been attributed to a number of factors: the shift in responsibility for
maternity care to obstetricians; the introduction of new antibiotics, the
establishment of blood banks (along with blood typing and transfusion
procedures); the introduction of safer types of anesthesia; and safer use
of forceps. A good portion of the decline from the mid-1950s is due to
declining infections related to septic abortion, resulting from the
liberalization of abortion laws starting in the early 1960s and the
legalization of abortion in 1970.

Although the timing of the decline in maternal mortality was late in the
United States relative to general declines in mortality, the same can be
observed for England and Wales. With improved living conditions (e.g.,
nutrition, sanitation), the nineteenth century saw reductions in infant
mortality and in deaths due to infection, with little benefit from medical
advances. However, reduction in maternal mortality had to wait upon the
development of medical interventions and procedures, and their proper use.
While later declines were dependent upon social and political change
(i.e., acceptance of abortion), the early and very large decline in
maternal mortality was the product of medical advance. The dependence of
safe childbirth on medicine is at odds with a trend commencing in the late
twentieth century in Western societies to return to an idealized
demedicalized childbirthing past. The evidence is compelling that medicine
is key to safe childbirth.

The contemporary maternal mortality ratio in the United States is 7.7, a
level that has remained unchanged since the early 1980s despite reductions
in general and infant mortality and despite a national goal to reduce
maternal mortality to no more than 3.3 by 2000. Part of the reason for the
failure to meet this goal is the existence of a persistent and large
racial difference in maternal mortality. African-American women—who
bear 16 percent of U.S. babies—have a maternity mortality

FIGURE 1

ratio (19.6) that is nearly four times higher than white women (5.3). The
reasons for the racial disparity are not clear. Some of the factors that
are likely involved include racial differences in susceptibility to high
blood pressure, a leading cause of maternal death; general health; and
receipt of high-quality prenatal care. However, generalizations are
difficult, especially given state differences. For example, the maternity
mortality ratio for African Americans varies from a low of 8.7 in
Massachusetts to a high of 25.7 in Washington, D.C.

The rate of decline in maternal deaths had stalled, and persistent racial
differences—showing a substantial African-American
disadvantage—remain. Yet, almost no research, either by biomedical
or by social scientists, is addressing these issues. As a result, the safe
motherhood goal of maternal mortality less than 3.3 has not been achieved
in America.